The effect of controlling medical expenses becomes increasingly obvious

Business Club December 17th The Ministry of Health issued the "Notice on Printing Clinical Pathways for Seven Diseases of Dermatology Specialties" on December 7th. In the previous year, there were 112 diseases that were clinically managed in the country. Pilot. Therefore, during the 64th National Pharmaceutical Fair, the topic of clinical pathway management and the reform of the medical insurance payment method based on this, has aroused great concern and discussion in the industry.

Experts in the industry pointed out that once the implementation of the clinical pathway management and medical insurance payment method reform is implemented, it will have an impact on the pricing mechanism and procurement mechanism of specialty drugs, and it will also increase the difficulty of clinical promotion of prescription drugs for pharmaceutical companies.

The effect is becoming increasingly apparent

In accordance with the relevant requirements of the "Five key reforms of the medical and health system in 2010", the Ministry of Health continued to promote the trial of clinical pathway management and added vitiligo, gonorrhea, chronic actinic dermatitis, and urticaria on December 7. The clinical path of seven diseases in the dermatoglycology department.

In December 2009, the Ministry of Health promulgated the "Clinical Pathway Management Pilot Work Plan" and made the clinical path management one of the core contents of the public hospital reform pilot work. Since the implementation of the Clinical Pathway Pilot Project in 2009, the Ministry of Health has issued 22 professional and 112 clinical pathways, and identified 110 hospitals in 23 provinces and municipalities as the pilot hospitals for clinical pathway management directly linked to the Ministry of Health.

After one year of trials, “the effect of clinical pathway management on improving the quality of medical care to control medical expenses has become increasingly apparent,” said Deng Haihua, spokesman of the Ministry of Health. Taking senile cataract surgery as an example, the average hospital stay dropped from 5.74 days to 4.95 days, and the average cost dropped from 7063.7 yuan to 6827.1 yuan, a decrease of 236.6 yuan. The cost of hospitalization with the most significant cost reduction dropped from 7,526 yuan to 5,012 yuan, a decrease of 33.4%.

"The clinical path has three characteristics. One is a single disease, the treatment is relatively simple and clear; the second is a patient with relatively simple conditions, no or less likely complications; the third is to cover the standardized management from preoperative to postoperative, A multi-departmental and multi-disciplinary management team, medical staff, and dietitians formed a management team,” Jiang Qin, an associate researcher at the Institute of Health Economics of the Ministry of Health, told a reporter from the “Medicine Economic News”.

Through the clinical path management can achieve three purposes: First, control of medical expenses; Second, to ensure a certain quality of medical services; Third, you can develop an average cost of hospitalization. Judging from relevant experience abroad, in countries such as the United States and Canada, we have already walked through a simple clinical pathway. Currently, we are implementing the management of diagnose affiliations (DRG) including clinical pathway management.

Change to prepayment and total control

According to the statistics of the Ministry of Health, in 2009, the total number of visits to medical institutions nationwide reached 5.49 billion, of which 13.25 million were admitted to hospitals, an increase of 15.4% over 2008; the per capita medical expenses of inpatients were as high as 5684.1 yuan, 8.6% more than in 2008, including drug costs 2480.6 Yuan, accounting for 43.6%.

“Clinical path management is a very good breakthrough for the reform of the medical insurance payment system and the control over the rapid growth of medical expenses.” Jiang Qin said that foreign DRG payment methods are paid according to the relevant diagnostic classification or paid by the type of disease.

In contrast to the DRG payment by disease category, it is the current “pay per project” method implemented in China. The biggest drawback caused by “paying by project” is that doctors open “big prescriptions” and hospitals provide over-medical services. Today, there are three main sources of revenue for hospitals: one is the price of medical services with low prices, the other is a portion with a slight balance, and the greater part is the income from medicines.

Wang Fanglin, Director of the Department of Health Insurance of the Ministry of Human Resources and Social Security, pointed out at the “China Pharmaceutical Distribution Industry Development Summit Forum” in the 64th China Pharmaceutical Fair on December 8 that as of the end of October 2010, the new rural cooperative medical system had covered 8.33. Billion people, urban workers’ medical insurance has covered 424 million people, urban residents’ medical insurance has covered 188.94 million people, and basic medical insurance has basically reached 90% of the total population (1.25 billion people).

Therefore, at the stage of the “Universal Medicare” system gradually taking shape, taking clinical pathway management as an entry point, controlling medical expenses, and exploring disease-based payouts on the basis of clinical pathways, it is becoming a focus of reforms in public hospital reform and medical insurance payment methods. direction.

“The Ministry of Human Resources and Social Security is studying the reform of the payment method, using prepayment and total control, such as outpatient and co-pay, and how much is about how many people, and then package it for a certain area of ​​a hospital. Through the payment method reform, to constrain doctors' medication. Behavior." Wang Fanglin pointed out.

It is noteworthy that hospitals are not motivated to determine the cost of single-disease payment according to the current price standards for medical services, because there is a high probability that they will lose much.

“Be sure to give the hospital motivation to do it. The cost criteria for single disease should consider the coverage of the population, but also consider the control of costs, but there is no need to control the absolute value of costs, but to optimize the hospital's cost and effectiveness of management, by reducing hospitalization. The number of days and the control of costs, etc., to the hospital incentive mechanism to save costs and reduce costs." Jiang Qin stressed.

Not a feast of cheap drugs

For the reform of the Medicare payment mechanism in development, Lin Jianning, director of the SFDA Southern Medicine Economic Research Institute, reminded that the reform of the Medicare payment system will bring about changes in the treatment plan and prescription structure, and the hospital will take the initiative to adjust the treatment methods and medication structure.

It is worth noting that the direction of the prepaid out-patient pay-per-paid reform combined with major illness and disease-based payment does not mean that the market share of low-priced drugs in hospitals will be promoted. "On the contrary, hospitals may prefer to use good medicines and consumables in order to save hospitalization time, reduce complications and ensure the quality of medical services," Jiang Qin pointed out.

In addition, according to relevant experience from abroad, the single-disease payout is only the output part of the entire management system, and the input part also includes the management of the price of drug consumables and the procurement mechanism. Therefore, under the single-disease payment-oriented approach, the health insurance agency that purchases medical and pharmaceutical services on behalf of the insured may be involved in the pricing and procurement management of medicines.

"The medical insurance agency represents the insured, establishes a cooperation and game mechanism with the medical service provider and the drug supplier, that is, in the case of commitment to purchase the number of services, negotiates prices with medical institutions and pharmaceutical companies, and prices of medical services and drugs The price of management, while reforming and improving the payment method." Wang Fanglin said.

In fact, the establishment of the access mechanism for high-priced drug insurance negotiations at the beginning of the year to the end of last year, as well as the newly promulgated “essential pricing, centralized procurement, and price-to-price ratios” in the basic drug procurement mechanism, may also be considered as the above-mentioned reform ideas. The first exploration.